JBDS hyperglycaemia and steroid therapy guideline

Management of hyperglycaemia and steroid (glucocorticoid) therapy

Introduction

The use of glucocorticoid treatment in people with pre-existing diabetes will undoubtedly result in worsening glucose control; this may be termed glucocorticoid-induced hyperglycaemia. This will warrant temporary additional and more active glycaemic management

A rise in glucose, related to glucocorticoid therapy occurring in people without a known diagnosis of diabetes is termed glucocorticoid-induced diabetes. This may or may not resolve when the glucocorticoids are withdrawn

In the outpatient population, 40% of glucocorticoid use is for respiratory disease, with most of the rest being used in musculoskeletal and cutaneous diseases, and conditions requiring immunosuppression. Most glucocorticoid use is for less than 5 days, but 22% is for greater than 6 months and 4.3% for longer than 5 years

Some patients may develop hyperglycaemia at a lower glucocorticoid dose, so clinical vigilance is, therefore, recommended with glucocorticoid therapy at any dose

Predisposing factors leading to increased risk of hyperglycaemia with glucocorticoid therapy

Pre-existing type 1 or type 2 diabetes

People at increased risk of diabetes (e.g. obesity, family history of diabetes, previous gestational diabetes, ethnic minorities, polycystic ovarian syndrome)

Monitoring guidance

In people without a pre-existing diagnosis of diabetes

Monitoring should occur at least once daily—preferably prior to lunch or evening meal, or alternatively

1–2 hours post lunch or evening meal. If the initial blood glucose is less than 12 mmol/l continue to test once prior to or following lunch or evening meal

If a subsequent capillary blood glucose is found to be greater than 12 mmol/l, then the frequency of testing should be increased to four times daily (before meals and before bed)

If the capillary glucose is found to be consistently greater than 12 mmol/l i.e. on two occasions during 24 hours, then the patient should enter the Management of glucocorticoid-induced diabetes algorithm (see below)

Management of glucocorticoid-induced diabetes

In people with a pre-existing diagnosis of diabetes

Test four times a day, before or after meals, and before bed, irrespective of background diabetes control

If the capillary glucose is found to be consistently greater than 12 mmol/l, i.e. on two occasions during 24 hours, then the patient should enter the Managing glucose control in people with known diabetes on once daily glucocorticoids algorithm (see below)

Managing glucose control in people with known diabetes on once daily glucocorticoids

Type 2 diabetes and glucocorticoid treatment—general guidance

Set target for capillary blood glucose (CBG) e.g. 6–10 mmol/l

Consider increasing monitoring to 4 times daily

Refresh diabetes education with patient

If hyperglycaemia on non-insulin therapies:

gliclazide—titrate to maximum of 320 mg daily, with maximum 240 mg in the morning

metformin—titrate to maximum of 1 g bd

If hyperglycaemia on insulin therapies:

if on evening once daily human insulin consider switch to morning dosing

if uncontrolled hyperglycaemia or multiple daily dosing of glucocorticoid consider switch to basal analogue insulin (or alternative regimen) and involve diabetes team in hospital or community

beware of nocturnal and early morning hypoglycaemia

Hospital discharge of patients at risk of glucocorticoid-induced diabetes/hyperglycaemia

Glucocorticoids commenced and patient discharged

Standard education for patient and carer

Blood glucose testing once daily (pre or post lunch or evening meal)

If blood glucose readings greater than 12 mmol/l increase frequency of testing to four times daily

If two consecutive blood glucose readings greater than 12 mmol/l in a 24 hour period follow algorithm for management of glucocorticoid-induced diabetes

Patient discharged on decreasing dose of glucocorticoid above 5 mg od

Standard education for patient and carer including advice on hypoglycaemia